Sections

Treatment

Approach Considerations

According to the National Comprehensive Cancer Network (NCCN), the goal of treatment for basal cell carcinoma (BCC) is elimination of the tumor with maximal preservation of function and physical appearance. As such, treatment decisions should be individualized according to the patient's particular risk factors and preferences.^[7]

In nearly all cases of BCC, the recommended treatment modality is surgery.^{[69, 7, 6]}The surgical approach varies according to tumor size, depth, and location. Dermatologists may perform nearly all of the therapeutic options in an outpatient setting. Most therapies are well established and widely applied; in addition, some other options are available (eg, photodynamic therapy with photosensitizers).^{[70, 71, 72]}

Local therapy with chemotherapeutic and immune-modulating agents is useful in some cases of BCC. In particular, small and superficial BCCs may respond to these compounds.

Topical 5% imiquimod is approved by the US Food and Drug Administration (FDA) for the treatment of nonfacial superficial BCCs that are less than 2 cm in diameter. Lesions are generally treated once daily, 5 days per week, for a duration of 6-12 weeks.

Likewise, topical fluorouracil is approved by the FDA for the treatment of superficial BCC, administered twice daily for 3-6 weeks.^[73]Although no formal restrictions on fluorouracil have been determined based on lesion size or location, it is most commonly used on smaller superficial BCCs on the trunk and extremities. Both imiquimod and fluorouracil may be used topically for prophylaxis or maintenance in patients who are prone to having many BCCs, likely by treating subclinical tumors.

For tumors that are more difficult to treat (ie, infiltrative BCC, morpheaform [sclerosing] BCC, micronodular BCC, and recurrent BCC) or those in which sparing normal (noncancerous) tissue is paramount, Mohs micrographic surgery should be considered and discussed with the patient.

Radiation therapy is a primary treatment option in patients who are not surgical candidates. It may also be used as adjuvant therapy in cases with positive surgical margins. However, radiation therapy is contraindicated in patients with genetic conditions that predispose to skin cancer.^[7]

A Hedgehog pathway inhibitor (HHI) can be used to treat patients with locally advanced BCC who are not candidates for surgery or radiation therapy, or whose disease has recurred after surgery or radiation therapy, and those with metastatic BCC.^[7]The FDA approved the first HHI pathway inhibitor, vismodegib (Erivedge), in 2012 and the second, sonidegib (Odomzo), in 2015. Those agents inhibit Smoothened (SMO), a transmembrane protein involved in Hedgehog pathway signal transduction.

In patients with metastatic BCC resistant to HHIs, treatment with arsenic trioxide and itraconazole may offer some benefit. Ally and colleagues reported that three of five men with resistant metastatic BC responded to a regimen of intravenous arsenic trioxide, 5 days every 28 days, and oral itraconazole on days 6 to 28. Although some patients experienced stable disease for 3 months, none had tumor shrinkage; the authors suggest that continuous dosing may be required to fully inhibit the Hedgehog pathway and achieve clinical response in such cases.^[74]

In February 2021, the first immunotherapy, cemiplimab (Libtayo), was fully approved for locally advanced BCC and granted accelerated approval for metastatic BCC previously treated with an HHI or for whom an HHI is not appropriate.

Surgical Modalities and Guidelines

The goal of therapy for patients with BCC is removal of the tumor with the best possible cosmetic result. By far, surgical modalities are the most studied, most effective, and most used BCC treatments. The effectiveness of surgical modalities depends heavily on the surgeon's skills; considerable differences in cure rates have been observed among surgeons. Modalities used include electrodesiccation and curettage, excisional surgery, Mohs micrographically controlled surgery, and cryosurgery.^{[75, 76, 77, 78]}

National Comprehensive Cancer Network (NCCN) guidelines recommend that low-risk BCC in non–hair-bearing areas be treated with curettage and electrodessication. If fat is reached, surgical excision should generally be performed. Standard excision is an alternative, if the lesion can be excised with 4-mm clinical margins and second-intention healing, linear repair, or skin graft. Margins should be assessed postoperatively. High-risk patients should undergo excision with postoperative margin assessment or a Mohs resection.^[7]

The American Academy of Dermatology, in collaboration with the American College of Mohs Surgery, the American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery, has developed appropriate use criteria for Mohs micrographic surgery. These include criteria for rating the appropriateness of Mohs micrographic surgery in 69 basal cell carcinoma scenarios.^[79]

Some studies suggest that dermato-oncological surgery is associated with a high risk of infection.^[40]This risk is greater in patients with diabetes and in those having such surgery in the thigh or lower leg and foot.

See Surgical Treatment of Basal Cell Carcinoma for more complete information on this topic.

Topical Treatments

Several topical creams are used in the management of BCC that is nonrecurring and superficial. NCCN guidelines state that low-risk patients with superficial BCC who cannot undergo surgery or radiation can be treated with topical therapies, although the cure rate may not be as high. Such treatments may also be used in patients with a high risk of multiple primary tumors.^[7]

Topical 5-fluorouracil 5%

Topical 5-fluorouracil 5% cream^[25]may be used to treat small, superficial BCCs in low-risk areas. It interferes with DNA synthesis by blocking methylation of deoxyuridylic acid and inhibiting thymidylate synthetase and, subsequently, cell proliferation.

In properly selected (eg, thin) tumors, cure rates of approximately 80% have been obtained. The cream is generally applied twice daily and must be used for at least 6 weeks for the treatment of superficial BCC.^[80]

Given that 5-fluorouracil can act on BCCs that are too small to be seen with the unaided eye, it may be used in patients with basal cell nevus syndrome or to preemptively treat subclinical tumors. Nevertheless, because not all tumors respond completely, careful patient monitoring is essential.

The use of 5-fluorouracil for other types of BCC is generally not recommended because it may not penetrate deeply enough into the dermis to eradicate all tumor cells. Irritation and crusting are common and expected; significant irritation and discomfort are not uncommon, but scars are unusual. The recurrence rate is very high.

Interferon

Interferon alfa-2b is a protein product manufactured using recombinant DNA technology. It has shown some success in treating small (< 1 cm), nodular, and superficial BCCs. In appropriate BCC tumors, cures rates of up to 80% have been obtained.

Several early studies have shown variable responses of BCC to intralesional interferon alfa. In a small study by Greenway et al, 1.5 million IU interferon alfa-2b injected intralesionally 3 times per week for 3 weeks resulted in the clearing of 3 cases of primary nonrecurrent BCC and 5 cases of primary superficial BCC.^[81]

Because larger studies are needed, most practitioners consider this an experimental therapeutic modality. Further data are needed before this treatment modality is recommended for routine ophthalmic practice.

Interferon has not become a mainstay in BCC treatment because of its cost, the inconvenience of multiple visits, the discomfort of administration, and its adverse effects, which include flulike symptoms. Acetaminophen may alleviate the flulike symptoms associated with this therapy.

Imiquimod

Imiquimod 5% cream (Aldara) is approved by the US Food and Drug Administration for the treatment of nonfacial superficial BCC.^{[82, 83]}Several studies have shown imiquimod to be curative in all patients with superficial BCC if used twice daily and in 73-82% of patients when used once a day for 6-12 weeks. Smaller studies have shown similar responses for nodular BCC. Studies for other histologic types of BCC are under way.^{[19, 20, 23, 22, 21, 24]}

Treatment is often initiated at 3-7 times per week and the dosage is increased as tolerated to once or twice daily, to maintain mild-to-moderate skin irritation.^{[84, 85]}Patients can titrate the frequency of application to maintain low-to-moderate skin irritation. A 12-week course of treatment is often used, which does not need be contiguous.^[75]

In a study of 601 patients with histologically proven superficial basal-cell carcinoma, topical imiquimod cream (once daily, 5 times a week, for 6 weeks) was superior, and topical fluorouracil (twice daily for 4 weeks) was noninferior, to methylaminolevulinate photodynamic therapy (2 sessions with an interval of 1 week). At both 3- and 12-month follow-up, the proportion of patients who were tumor-free was 72.8% for methylaminolevulinate photodynamic therapy, 83.4% for imiquimod cream, and 80.1% for fluorouracil cream.^[86]

Tazarotene

The receptor-selective acetylenic retinoid tazarotene (Tazorac) can also be used to treat small low-risk BCCs. Tazarotene is thought to cause BCC regression by increasing apoptosis and by decreasing cell proliferation in the skin cancer cells. In one case series, about 70.8% of the BCCs had clinical and dermoscopic regression of more than 50%, and 30.5% healed without recurrence after 3 years; most unresponsive tumors showed keratotic differentiation. The study involved the application of tazarotene 0.1% gel for 24 weeks in 154 small, superficial, and nodular BCCs (109 patients). Changes were followed up by dermoscopy and histologic examination.^[87]

In addition to being an off-label indication, another drawback to topical tazarotene for the treatment of BCC is that it requires long-term therapy, for 5-8 months. The only reported adverse effect is dry/irritating skin that is relieved after discontinuation of tazarotene.

Radiation Therapy

Basal cell carcinomas (BCCs) are usually radiosensitive, and radiation therapy (RT) can be used for advanced and extended lesions and in those patients for whom surgery is not suitable (eg, because of allergy to anesthetics, current anticoagulant therapy, a tendency to form keloids,^[88]or facial tumors). In a retrospective analysis of 1715 histologically confirmed primary cutaneous carcinomas (712 BCCs, 994 SCCs, nine tumors with distinct BCC and SCC characteristics) treated with superficial radiation therapy, recurrence rates for BCC at 2 and 5 years were 2% and 4.2%, respectively. Recurrence rates for SCC at 2 and 5 years were 1.8% and 5.8%, respectively.^[89]Postoperative radiation can also be a useful adjunct when patients have aggressive tumors that were treated surgically or when surgery has failed to clear the margins of the tumor.^[8] The treatment of locally advanced basal cell carcinomas may result in complete remission in approximately 70% of patients.^[90]

In the past, RT was a common treatment modality because of its high cure rate (97% for primary tumors). It is now used sparingly, because it is time consuming and extremely expensive. With the advancement in surgical techniques and other treatment modalities, RT is a reasonable treatment choice for recurrent tumors. It may be reserved for primary lesions requiring difficult or extensive oculoplastic surgery. It also eliminates the need for skin grafting when surgery would result in an extensive defect.

RT is contraindicated in young patients because of the high risk of radiodermatitis and scars; in lesions on the trunk and extremities; and in delayed cancer recurrence (eg, especially in patients previously treated with radiation). RT requires multiple visits. Treatment results in radiation damage and, therefore, should be reserved for older patients. RT is less effective for nonfacial tumors.

RT also is contraindicated in patients with connective tissue diseases or genetic conditions predisposing to skin cancer (eg, xeroderma pigmentosum, epidermodysplasia verruciformis, and basal cell nevus syndrome.) This histologic type in conjunction with RT may induce more tumors in the treated area. Radiation adverse effects include dermatitis, keratinization of the conjunctiva, and chronic keratitis.

Cosmetic results are generally good to excellent, with a small amount of hypopigmentation or telangiectasia in the treatment port. This therapy can be less disfiguring than surgical excision. Nevertheless, long-term results after several years can be deforming. Another disadvantage of this technique is that surgical margins cannot be examined. Tumors recurring in previously radiated sites tend to be aggressive and difficult to treat and reconstruct. RT remains an important, feasible option in selected patients with BCC.

The NCCN guideline supports RT for patients whose condition is appropriate, with the reservation that in order to achieve its benefits (high cure rates and good comesis), it must be administered carefully and with attention to algorithm details by well-trained specialists. Training and proper support are particularly essential to the use of intensity modulated RT as primary treatment. Medical physicists must provide the necessary support and training in this new technology.^[7]

Photodynamic Therapy

Photodynamic therapy (PDT) for basal cell carcinomas (BCCs) has been used for more than 20 years.^{[91, 92]}PDT is the process of using specific wavelengths of light to photoexcite porphyrins that have been applied to neoplastic and preneoplastic cells. This increased energy is rapidly absorbed by adjacent tissue oxygen, causing the formation of singlet oxygen radicals. These radicals rapidly react with adjacent tissue and destroy it. 5-Aminolevulinic acid (ALA-PDT) is the only US Food and Drug Administration approved photoreactive molecule for PDT in the United States, and it is only approved for actinic keratoses. It is photoactivated with blue light for 1000 seconds after 1 hour of incubation.

PDT is administered orally or parenterally, as well as applied topically, and localizes into tumor cells before activation by exposure to light (eg, laser). The efficacy is low, and this treatment is frequently palliative. PDT may cause local edema, erythema, blistering, and ulceration, but the final cosmetic effect is good.

PDT yielded only a 50% cure rate for superficial BCC, versus an 83% cure rate for nodular BCC, in a study by Calzavara-Pinton et al.^[93]At present, PDT has no distinct advantage over other well-established therapies for BCC of the eyelid. In a study by Puccioni et al, PDT using methyl aminolevulinate showed notable success and appears to be a viable option in the treatment of BCC of the eyelid in selected patients.^[94]

PDT as an adjunct is a reasonable choice in the following cases:

Tumor recurrence with tissue atrophy and scar formation
Elderly patients or patients with medical conditions preventing extensive oculoplastic reconstructive surgery
Tumor with poorly defined borders based on clinical examination
Tumor requiring difficult or extensive oculoplastic surgery

Although its use is off label, PDT has been used for treatment and prevention of BCCs, including those patients with immunosuppression and nevoid BCC syndrome. Shallow tumors, such as superficial BCCs, respond most consistently. Surgical excision has been shown to be significantly more effective than ALA-PDT in the treatment of nodular BCC.^[95]

The strongest support for PDT as a modality for BCCs comes with data on thin lesions treated with methylaminolevulinate (used outside the United States), but at least one long-term follow-up trial has also shown surgical excision to be superior.^[96]

Christensen et al reported a 10-year lesion complete response rate of 87% with two sessions of dimetylsulfoxide-supported topical 5-aminolaevulinic acid-PDT and curettage for primary, small BCC. Favourable cosmetic outcomes also were reported for nearly all cases.^[97]

Various protocols have been followed to achieve varying levels of success—increasing incubation time, increasing occlusion time, and using longer and/or deeper-penetrating wavelengths of light (eg, red light or pulse-dye laser). Many patients continue to prefer PDT because of its short healing time, excellent cosmesis, and relative affordability.

Also see the British Association of Dermatologists Therapy Guidelines and Audit Subcommittee’s clinical guidelines summary, Guidelines for topical photodynamic therapy: update.^[92]

Systemic Retinoids

Although several clinical trials have shown some efficacy for available systemic retinoids in chemotherapy and chemoprevention, the long-term toxicity of these agents generally excludes them as treatment choices for most patients.^[98]Studies are exploring their value as cancer preventive agents in patients at high risk for developing multiple tumors.

Vismodegib

Vismodegib (Erivedge) is the first FDA-approved drug for advanced forms of basal cell carcinoma (BCC). It selectively inhibits Smoothened (SMO), a key transmembrane protein involved in Hedgehog signal transduction of cancerous epithelial cells.^[99]FDA approval was based on a single, international, open-label trial (n=104). Of the 104 participants, 96 were evaluable. Of those with metastatic BCC (n=33), 30.3% had partial response, but none had complete response. With locally advanced BCC (n=63), 22% showed a partial response and 20% showed complete response.^[100]

Sonidegib

A second Hedgehog pathway inhibitor (HHI), sonidegib (Odomzo), was approved by the FDA in 2015. Approval was based on the BOLT trial in patients had locally advanced BCC not amenable to curative surgery or radiation or metastatic basal cell carcinoma. Patients were randomized in a 1:2 ratio to receive 200 mg or 800 mg oral sonidegib daily, stratified by disease, histological subtype, and geographical region. For the 66 patients in the 200 mg group, the overall response rate was 58%; 3 patients (5%) achieved a complete response and 35 (53%) achieved a partial response. The duration of response ranged from 1.9 to 18.6 months, and in approximately half of the responding patients, the tumor shrinkage lasted at least 6 months.^[101]

Checkpoint Inhibitor

Cemiplimab, a programmed death 1 (PD-1) inhibitor, was the first immunotherapy approved by the FDA for advanced BCC after Hedgehog pathway inhibition. In 2021, it was fully approved for patients with locally advanced BCC and granted accelerated approval for patients with metastatic BCC (mBCC).

Approval for locally advanced BCC was based on a phase II, nonrandomized, open-label trial, Study 1620. Patients (n=112) with locally advanced or metastatic BCC (mBCC) whose BCC had progressed on HHI or who were not candidates for HHI therapy received cemiplimab until disease progression, unacceptable toxicity, or completion of planned treatment. The confirmed objective response rate was 29% (95% CI: 19, 40) for patients with locally advanced BCC and 21% (95% CI: 8, 41) for those with mBCC. Observed duration of response (DOR) for at least 6 months was reported in 79% of locally advanced BCC responders and all mBCC responders. For both treatment groups, median DOR was not reached.^[102]

Recurrence

The following is a list of treatments and their 5-year recurrence rates for primary BCCs:

Surgical excision - 10.1%
Radiation therapy - 8.7%
Curettage and electrodesiccation - 7.7%
Cryotherapy - 7.5%
All non-Mohs modalities - 8.7%
Mohs micrographic surgery - 1.0%

These rates are probably affected by the fact that most clinicians use cryotherapy, curettage, and desiccation mostly on smaller and better-demarcated lesions.

Prevention

Avoid possible potentiating factors (eg, sun exposure, ionizing radiation, arsenic ingestion, tanning beds). The regular use of sun-protecting clothing (eg, wide-brimmed hat, long-sleeved shirts, sunglasses with ultraviolet [UV] protection) is recommended when outdoors. Instruct patients to avoid sun exposure particularly during the middle of the day (ie, 11 am to 3 pm), which is the most dangerous time. Also, the sun's rays are especially intense in sunny climates and at high altitudes, and UV radiation can also pass through clouds and water. Patients should be instructed to be careful on the beach and in the snow because sand, water, and snow reflect sunlight and increase the amount of received UV radiation.

Researchers are investigating chemoprevention with systemic administration of retinoids as cancer preventive agents in patients at high risk for developing basal cell carcinoma; the efficacy of these agents will take several years to evaluate, however.

The American Cancer Society recommends a dermatologic examination every 3 years for people aged 20-40 years and every year for people older than 40 years. The US Preventive Services Task Force determined that insufficient evidence exists to make a recommendation on asymptomatic adults receiving skin cancer screenings from a clinician.^[103]

Consultations

Ideally, treatment options for the patient with basal cell carcinoma should be evaluated jointly with a surgeon, dermatologist, and radiotherapist and based on histologic diagnosis.

Although early basal cell carcinoma can be treated adequately by means of local excision, advanced and recurrent tumors are best managed by a multidisciplinary approach involving head and neck surgical oncologists, Mohs micrographic surgeons, reconstructive plastic surgeons, pathologists, prosthetists, and radiation oncologists.

Long-Term Monitoring

Mc Loone et al found that patients who are diagnosed with BCC have a 35% chance of developing another tumor within 3 years and a 50% chance of developing another (not recurrent) BCC within 5 years.^[49]The NCCN guidelines state that 30-50% of patients will develop another nonmelanoma skin cancer within 5 years. These patients are also at an increased risk of developing cutaneous melanoma.^[7]Therefore, regular skin screenings are recommended.^{[49, 7]}

Fewer than 1% of BCCs spread to another site in the body; nevertheless, after treatment, which is curative in more than 95% of cases, BCC may develop in new sites. Recommend appropriate prolonged or lifelong follow-up care.

Tumors occurring after radiotherapy tend to be more aggressive and infiltrative than other tumors. Metastasis is rare but has been reported with rates of 0.01-0.1%. Metastases most often originate from large, ulcerated tumors. Metastases usually occur in regional lymph nodes. Follow-up visits are scheduled 3 months after therapy and every 6 months to 1 year thereafter for the life of the patient.

Guidelines

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Media Gallery

A pink, scaly lesion on the skin. Superficial basal cell carcinoma (BCC) is often misdiagnosed as eczematous dermatitis or guttate psoriasis and is often difficult to distinguish clinically from Bowen disease (squamous cell carcinoma in situ). Features that suggest the diagnosis of superficial BCC are the absence of significant white, adherent scale and a history of the lesion remaining unchanged for several months or years. Treatment options for this tumor include electrodesiccation and curettage, surgical excision, cryosurgery, 5-fluorouracil, 5% imiquimod cream, and superficial radiotherapy. Electrodesiccation and curettage is the modality most commonly used, with a cure rate of approximately 95%.
Basal cell carcinoma.
A 68-year-old patient presenting with an advanced basal cell carcinoma (BCC) of the right periorbital region, frontal view. Courtesy of M Abraham Kuriakose, DDS, MD.
Lateral view of face showing extent of tumor. Courtesy of M Abraham Kuriakose, DDS, MD.
Basal cell carcinoma of the right lower lid.
Biopsy-proven basal cell carcinoma of the upper lid margin. Note the loss of cilia (madarosis) in the area of the tumor.
Medial canthal/lower lid basal cell. Note the pearly nodular surface with characteristic telangiectatic vessels. Proximity to the lacrimal system will impact its treatment and reconstruction.
Nodular basal cell carcinoma.
Nodular basal cell carcinoma appearing as a waxy, translucent papule with central depression and a few small erosions.
Scale, erythema, and a threadlike raised border are present in this superficial basal cell carcinoma on the trunk.
Large, superficial basal cell carcinoma.
Basal cell carcinoma. Courtesy of Hon Pak, MD.
Pigmented basal cell carcinoma.
Pigmented basal cell carcinoma.
Pigmented basal cell carcinoma has features of nodular basal cell carcinoma with the addition of dark pigmentation from melanin deposition. The pigmentation often has the appearance of dark droplets in the lesion, as shown here.
This infiltrating basal cell cancer has ill-defined borders and telangiectases.
This translucent pink papule has telangiectases and a crusted erosion, characteristic of nodular basal cell carcinoma.
Large, scarlike morpheaform basal cell cancer.
Nodular basal cell carcinoma. Nodular aggregates of basalioma cells are present in the dermis and exhibit peripheral palisading and retraction artifact. Melanin is also present within the tumor and in the surrounding stroma, as seen in pigmented basal cell carcinoma.
Histologic pattern of a well-differentiated basal cell carcinoma (original magnification X140). Courtesy of Prof Pantaleo Bufo, University of Foggia, Italy.
Histologic pattern of a well-differentiated basal cell carcinoma (original magnification X250). Courtesy of Prof Pantaleo Bufo, University of Foggia, Italy.
Micronodular basal cell carcinoma often has an absence of retraction artifact. The characteristic histology is small size and uniformity of the tumor nodules. Courtesy of Shang I Brian Jiang, MD.
Infiltrative basal cell carcinoma. Tumor cells are arranged in narrow strands, and mucin-rich stroma is often present. Courtesy of Shang I Brian Jiang, MD.
Keratotic basal cell carcinoma. Rare type characterized by keratocysts. Courtesy of Shang I Brian Jiang, MD.
Basosquamous basal cell carcinoma. Foci of neoplastic cells with squamous differentiation are present. Courtesy of Shang I Brian Jiang, MD.
Histology of superficial basal cell carcinoma. Nests of basaloid cells are seen budding from the undersurface of the epidermis. Courtesy of Michael L Ramsey, MD.

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Author

Robert S Bader, MD Dermatologist, Section of Dermatology, Department of Medicine, Broward Health - North

Robert S Bader, MD is a member of the following medical societies: American Academy of Dermatology, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Florida Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Received income in an amount equal to or greater than $250 from: Elsevier; WebMD<br/>Served as a speaker for various universities, dermatology societies, and dermatology departments.

Chief Editor

Mark S Granick, MD, FACS Professor of Surgery, Division of Plastic Surgery, Rutgers New Jersey Medical School; Professor of Surgery, Rutgers Robert Wood Johnson Medical School; Medical Director, University Hospital Wound Care Center

Mark S Granick, MD, FACS is a member of the following medical societies: American Association of Plastic Surgeons, American College of Surgeons, American Society of Plastic Surgeons, New Jersey Society of Plastic Surgeons, Northeastern Society of Plastic Surgeons, Phi Beta Kappa, Wound Healing Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: PolarityTE; Misonix<br/>Serve(d) as a speaker or a member of a speakers bureau for: Misonix, PolarityTE<br/>Received income in an amount equal to or greater than $250 from: Misonix, PolarityTE.

Additional Contributors

Andrew S Kennedy, MD, FACRO Physician-in-Chief, Radiation Oncology, Sarah Cannon; Director, Radiation Oncology Research, Sarah Cannon Research Institute

Andrew S Kennedy, MD, FACRO is a member of the following medical societies: Alpha Omega Alpha, American Association for Cancer Research, American Society for Radiation Oncology, American Society of Clinical Oncology, Americas Hepato-Pancreato-Biliary Association, Radiological Society of North America

Disclosure: Nothing to disclose.

Luigi Santacroce, MD Assistant Professor, Medical School, State University at Bari, Italy

Disclosure: Nothing to disclose.

Laura Diomede University of Bari School of Medicine, Italy

Disclosure: Nothing to disclose.

Acknowledgements

Sanjiv S Agarwala, MD Chief of Oncology and Hematology, St Luke's Cancer Center, St Luke's Hospital and Health Network; Professor, Temple University School of Medicine

Sanjiv S Agarwala, MD is a member of the following medical societies: American Association for Cancer Research, American Society for Head and Neck Surgery, American Society of Clinical Oncology, Eastern Cooperative Oncology Group, and European Society for Medical Oncology

Disclosure: BMS Honoraria Speaking and teaching; Novartis Consulting fee Consulting; Merck Consulting fee Consulting

Michael G Barkett, MD, MS Cardiovascular Diseases, Department of Medicine, Advocate Aurora Health

Disclosure: Nothing to disclose.

Daniel Berg, MD, FRCP(C) Professor of Dermatology, Director of Dermatologic Surgery, University of Washington School of Medicine

Daniel Berg, MD, FRCP(C) is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Mohs Micrographic Surgery and Cutaneous Oncology, and American Society for Dermatologic Surgery

Disclosure: Genentech Honoraria Review panel membership

Gregory Caputy, MD, PhD, FICS Chief Surgeon, Aesthetica Plastic and Laser Surgery Center, Inc

Gregory Caputy, MD, PhD, FICS is a member of the following medical societies: American Society for Laser Medicine and Surgery, International College of Surgeons, International College of Surgeons US Section, Pan-Pacific Surgical Association, and Wound Healing Society

Disclosure: Syneron Corporation Salary Speaking and teaching

Edward F Chan, MD Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania School of Medicine

Edward F Chan, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Robert A Copeland Jr, MD Chair, Professor, Department of Ophthalmology, Howard University College of Medicine

Robert A Copeland Jr, MD is a member of the following medical societies: American Academy of Ophthalmology

Disclosure: Nothing to disclose.

Mark T Duffy, MD, PhD Consulting Staff, Division of Oculoplastic, Orbito-facial, Lacrimal and Reconstructive Surgery, Green Bay Eye Clinic, BayCare Clinic; Medical Director, Advanced Cosmetic Solutions, A BayCare Clinic

Mark T Duffy, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Ophthalmic Plastic and Reconstructive Surgery, Sigma Xi, and Society for Neuroscience

Disclosure: Allergan - Botox Cosmetic Honoraria Speaking and teaching

Hon-Vu Q Duong, MD Clinical Instructor of Ophthalmology and Ophthalmic Pathology, Westfield-Nevada Eye and Ear; Senior Lecturer of Neurosciences:Anatomy and Physiology, Nevada State College

Hon-Vu Q Duong, MD is a member of the following medical societies: American Academy of Ophthalmology

Disclosure: Nothing to disclose.

Dirk M Elston, MD Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Jaime R Garza, MD, DDS, FACS Consulting Staff, Private Practice

Jaime R Garza, MD, DDS, FACS is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Society for Aesthetic Plastic Surgery, American Society of Maxillofacial Surgeons, Texas Medical Association, and Texas Society of Plastic Surgeons

Disclosure: Allergan None Speaking and teaching; LifeCell None Consulting; GID, Inc. Grant/research funds Other

Shahin Javaheri, MD Chief, Department of Plastic Surgery, Martinez Veterans Affairs Outpatient Clinic; Consulting Staff, Advanced Aesthetic Plastic & Reconstructive Surgery

Shahin Javaheri, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery and American Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Shang I Brian Jiang, MD Associate Clinical Professor of Medicine and Dermatology, Director, Dermatologic and Mohs Micrographic Surgery, Program Director, UCSD Dermatologic and Mohs Surgery Fellowship, University of California School of Medicine, San Diego

Shang I Brian Jiang, MD, is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery, and Association of Professors of Dermatology

Disclosure: DUSA Corporation Grant/research funds PI for Industry Sponsored Clincal Trial

Klaus-Dieter Lessnau, MD, FCCP Clinical Associate Professor of Medicine, New York University School of Medicine; Medical Director, Pulmonary Physiology Laboratory; Director of Research in Pulmonary Medicine, Department of Medicine, Section of Pulmonary Medicine, Lenox Hill Hospital

Klaus-Dieter Lessnau, MD, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Medical Association, American Thoracic Society, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society

Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation Unrestricted gift Unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Medvoy Ownership interest Management position; Cerescan Imaging Consulting; Headwatersmb Consulting fee Consulting; Venturequest Royalty Consulting

Maurice Y Nahabedian, MD, FACS Associate Professor, Department of Plastic Surgery, Georgetown University Hospital

Maurice Y Nahabedian, MD, FACS is a member of the following medical societies: American Association of Plastic Surgeons, American College of Surgeons, American Society for Reconstructive Microsurgery, American Society of Plastic Surgeons, Johns Hopkins Medical and Surgical Association, and Northeastern Society of Plastic Surgeons

Disclosure: Lifecell corp Honoraria Speaking and teaching

Samia Nawaz, MBBS, MD Associate Professor, Department of Pathology, University of Colorado Health Science Center

Samia Nawaz, MBBS, MD is a member of the following medical societies: American Society for Clinical Pathology, American Society of Cytopathology, and International Academy of Pathology

Disclosure: Nothing to disclose.

Ron W Pelton, MD, PhD Private Practice, Colorado Springs, Colorado

Ron W Pelton, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, American Society of Ophthalmic Plastic and Reconstructive Surgery, AO Foundation, and Colorado Medical Society

Disclosure: Nothing to disclose.

Michael L Ramsey, MD Director, Mohs Surgery Fellowship, Co-Director, Procedural Dermatology Fellowship, Department of Dermatology, Geisinger Medical Center

Michael L Ramsey, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Micrographic Surgery and Cutaneous Oncology, and Pennsylvania Academy of Dermatology

Disclosure: Nothing to disclose.

Rana Rofagha Sajjadian, MD Clinical Instructor, Department of Dermatology, University of Irvine, California; Division of Mohs Surgery, Department of Dermatology, Southern California Permanente Medical Group

Rana Rofagha Sajjadian, MD is a member of the following medical societies: American Academy of Dermatology, American Society for Dermatologic Surgery, and American Society for MOHS Surgery

Disclosure: Nothing to disclose.

Thomas M Roy, MD Chief, Division of Pulmonary Diseases and Critical Care Medicine, Quillen Mountain Home Veterans Affairs Medical Center; Professor, Department of Internal Medicine, Division of Pulmonary Medicine, Fellowship Program Director, East Tennessee State University, James H Quillen College of Medicine

Thomas M Roy, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Medical Association, American Thoracic Society, Southern Medical Association, and Wilderness Medical Society

Disclosure: Nothing to disclose.

M Sherif Said, MD, PhD Associate Professor of Pathology, Director of Head and Neck Pathology, Department of Pathology, University of Colorado School of Medicine

M Sherif Said, MD, PhD is a member of the following medical societies: American Society for Clinical Pathology and College of American Pathologists

Disclosure: Nothing to disclose.

Ali Sajjadian, MD, FACS Private Practice, Newport Beach, California; Former Assistant Professor of Plastic Surgery, Former Director of Aesthetic Plastic Surgery Satellite Centers, University of Pittsburgh Medical Center

Ali Sajjadian, MD, FACS is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society of Plastic Surgeons, American Society of Plastic Surgeons, American Society of Plastic Surgeons, California Medical Association, Northeastern Society of Plastic Surgeons, and PennsylvaniaMedical Society

Disclosure: Nothing to disclose.

Negar Sajjadian, MD Assistant Professor of Pediatrics, Tehran University of Medical Sciences, Shariati Hospital

Disclosure: Nothing to disclose.

Wayne Karl Stadelmann, MD Stadelmann Plastic Surgery, PC

Wayne Karl Stadelmann, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Society of Plastic Surgeons, New Hampshire Medical Society, Northeastern Society of Plastic Surgeons, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Katherine Szyfelbein, MD Staff Physician, Department of Dermatology, Boston University, Boston Medical Center

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

R Stan Taylor, MD The JB Howell Professor in Melanoma Education and Detection, Departments of Dermatology and Plastic Surgery, Director, Skin Surgery and Oncology Clinic, University of Texas Southwestern Medical Center

R Stan Taylor, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Surgery, American Dermatological Association, American Medical Association, American Society for Dermatologic Surgery, Christian Medical & Dental Society, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Basal Cell Carcinoma Treatment & Management

Approach Considerations

Surgical Modalities and Guidelines